IBEW / NECA SOUND & COMMUNICATIONS HEALTH & WELFARE PLAN 2015 MEDICAL PLAN OPTIONS BENEFIT SUMMARY MEDICAL

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1 IBEW / NECA SOUND & COMMUNICATIONS HEALTH & WELFARE PLAN 2015 PLAN OPTIONS BENEFIT SUMMARY Two Medical plan options are offered: 1) The Trust Self-Funded Medical Indemnity Plan (a PPO Plan) and 2) Kaiser Permanente (an HMO Plan). With two options, you are able to select the plan that works best for your needs. PLAN FEATURES Provider Network Anthem Blue Cross PPO Use Any Provider Kaiser Permanente Network Service Area California California Who Provides Care / Provider Choice Calendar-Year Deductible Calendar-Year Out-of-Pocket Maximum for Covered Expenses Medical Plan Annual Maximum Medical Plan Lifetime Maximum Eligibility Age Limits for Dependent Children Preauthorization Requirements Any medical provider. To receive the highest level of benefits, use an Anthem Blue Cross PPO network provider. Note: If you are referred to an out-of-network provider by an in-network provider, out-of-network benefits still apply. $2,500 per person, up to $5,000 per family Your physician is responsible for obtaining any required preauthorization through Anthem Blue Cross. Under age 26. You or your physician must contact Anthem Blue Cross at least seven days before: Hospital admission Use of outpatient facility Certain diagnostic procedures Outpatient surgery Kaiser Permanente doctors and facilities only None $1,500 per person, up to $3,000 per family Same All preauthorizations must be coordinated through your Kaiser physician. D:\Documents and Settings\jkeith\Desktop\websites\sound\Open Enrollment Benefits Summary Chart 2015.doc 1 of 6

2 Benefits for Most Covered Services rate except for inpatient Hospital 90% of Anthem Blue Cross negotiated rate for inpatient Hospital You pay a $15 copay per visit. No benefits are payable at non- Kaiser facilities, except in case of emergency. Preventative Care Benefits Preventative Physical Exams Well Baby Care Immunizations and Vaccinations Plan pays 100% of eligible expenses for annual preventative physical exam in an Anthem Blue Cross network provider doctor s office. Age frequency applies. Plan pays 80% of Anthem Blue Cross negotiated rate up to 8 well baby visits. (Infants through age 36 months) Plan pays 100% for children up to 36 months of age for physicianrecommended immunizations and vaccinations. No benefit provided out-of-network. Plan pays 100%. Annual routine physical examinations for employment, sports, college entrance, etc. not covered. No benefit provided out-of-network Plan pays 100%. (Infants through age 23 months) No benefit provided out-of-network Plan pays 100%. For children under 2 years of age, refer to Well Baby Care. Diagnostic Test (X-Ray, Blood Work) Plan pays 100% of Anthem Blue Cross PPO network provider services. Calendar-year deductible is waived. Plan pays 100%. Imaging (CT / PET scans, MRI s) Plan pays 80% of Anthem Blue Cross negotiated rate. Plan pays 100%. Infertility Treatment No benefit provided. Limited benefits. Contact Kaiser for specific coverage. 2 of 6

3 Inpatient Hospital and Outpatient Facility Services 90% of Anthem Blue Cross negotiated rate; calendar-year deductible is waived when admitted to an in-network inpatient facility. See preauthorization requirements. Inpatient Plan pays 100% after you pay $100 copay per admission. Outpatient Plan pays 100% after you pay $15 copay per procedure. Emergency Room Facility Charges Plan pays 80% of Anthem Blue Cross negotiated rate. reasonable Plan pays 100% after you pay $100 copay. Copay is waived if you are admitted to hospital as inpatient. Urgent Care Center Services Plan pays 100% after you pay rate. $15 copay. Ambulance Plan pays 100%. Chiropractic and Acupuncture Services Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) rate. rate up to 20 visits per calendar year. charges up to 20 visits per calendar year. rates. You pay a $15 copay per visit for up to 30 visits per calendar year. You pay a $15 copay per visit. 3 of 6

4 MENTAL HEALTH BENEFIT Calendar Year Deductible None Calendar-Year Out-of-Pocket Maximum $2,500 per person, up to $5,000 per family $1,500 per person, up to $3,000 per family Mental / Behavioral Health Inpatient Services days based on medical Plan pays 90% of Optum Health s days based on medical You pay $100 copay per admission at Kaiser facilities. Mental / Behavioral Health Outpatient Services visits based on medical Plan pays 80% of Optum Health s visits based on medical You pay $15 copay per visit (individual basis) or $7 copay per visit (group basis) at Kaiser facilities. PLAN FEATURES Substance Abuse Disorder Outpatient Services Substance Abuse Disorder Inpatient Services SUBSTANCE ABUSE BENEFIT visits based on medical Plan pays 80% of Optum Health s days based on medical Plan pays 90% of Optum Health s visits based on medical days based on medical You pay $15 copay per visit (individual basis) or $5 copay per visit (group basis) at Kaiser facilities. You pay $100 copay per admission at Kaiser facilities. 4 of 6

5 Prescription Drugs Retail Drugs (up to 30-day supply) Only at participating pharmacies Generic You pay $10 copay. Preferred Brand You pay 20%; $15 minimum up to a $25 maximum copay. Non-Preferred Brand You pay 30%; $30 minimum up to a $75 maximum copay. Mail Order Drugs (up to 90-day supply) Only through Postal Prescription Services (PPS) Generic You pay $20 copay. Preferred Brand You pay 20%; $40 minimum up to a $75 maximum copay. Non-Preferred Brand You pay 30%; $75 minimum up to a $150 maximum copay. Some drugs require preauthorization. Retail Drugs (up to 30-day supply) Only at Kaiser pharmacy Generic You pay $10 copay. Brand You pay $25 copay. Mail Order Drugs refills only (up to 100-day supply) Only through Kaiser Mail Order Service Generic You pay $20 copay. Brand You pay $50 copay. Not all drugs are available through mail order. Medical plan deductible and coinsurance amounts do not apply to this benefit feature. 5 of 6

6 PROVIDER CONTACT INFORMATION Member / Customer Service Phone, United Administrative Services (Plan Administrator) (408) GROUP # Anthem Blue Cross Preferred Provider Organization (PPO) (Refer to Group #170016) (408) VISION SERVICE PLAN OPTUMHEALTH FIRST DENTAL HEALTH DENTAL PPO RESTAT Rx POSTAL PRESCRIPTION SERVICES (Mail Order Rx) All information contained in this benefit summary has been designed to give you a general overview of the Medical plan options and the Medical benefits provided effective January 1, It does not, however, attempt to explain all the details, provisions, limitations, restrictions and exclusions of the Plan s Medical benefits. The Board of Trustees reserves the right to change or terminate the Plan or specific provisions of the Plan at any time. If there is any conflict between this benefit summary and the Plan s Summary Plan Description (SPD), the SPD prevails. For additional information about the Plan s benefits, please contact the Plan Administrator, United Administrative Services: (408) or toll-free, of 6